If not referring directly on to Abritas please email this form to:
Floating Support:
floating.support@newport.gov.uk
or
Supported Housing: newport.gateway@newport.gov.uk
Housing-Related Support Referral (Application) and Risk Form
for floating support & supported housing schemes in Newport
This referral form is available in Welsh upon request.
1. Referrer details
Name of
Referrer
Date of
Referral
Position
Agency
Contact
Number
E-mail
2. Support Type required
Support
Supported Accommodation
Required
3. Area of Residence
If floating support:
does the applicant live in
Newport?
If supported accommodation:
has a local connection to
Newport been established?
☐
Floating Support
Yes
☐
No
☐
Yes
☐
No
☐
☐
If yes to the above please
detail
4. Applicant details
Name
(incl title)
Abritas Number
(if applicable)
DOB
Gender
NI No
SWIFT Number
(if applicable)
Marital
Status
Is applicant
disabled?
Yes
No
☐
☐
If disabled
give details:
Nationality
Ethnic Origin
5. Address details
Current
Address
Is this address (please tick)
Home
☐
Work
☐
Family ☐
Date Moved In
Landlord Name & Address
(if applicable)
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Friends ☐
Solicitor
☐
Accommodation Type
(renting RSL or private, owner
occupier, NFA etc)
Is the applicant at risk of
homelessness?
Reason for leaving last
accommodation?
Does the applicant live alone?
Yes
☐
No
☐
Yes
☐
No
☐
If no, please detail
6. Contact details
Applicant Home Tel
Applicant Mobile Tel
Applicant Email Address
Preferred Method of Contact
OR alternative contact details
7. Other details
Does the applicant have any
communication issues?
Are there any cultural issues
we should be aware of?
Please list any other type of
support or services that are in
place
Indicate issues of the applicant
(please tick all that are
relevant):
1. Domestic Abuse
(Men, Women & Families)
2. Learning Disability
3. Mental Health
4. Alcohol
5. Substance Misuse
6. Criminal Offending History
7. Refugee Status
8. Physical/Sensory Disabilities
9. Developmental Disorder
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10.Dual Diagnosis
☐
11. Chronic Illness (inc HIV & AIDS) ☐
12.
13.
14.
15.
16.
17.
18.
19.
Young Care Leavers
Young People (16 to 24 years)
Single Parent Families
Families
Single People (25 to 54 years)
People aged 55+
Memory Loss/Dementia
Generic
☐
20. Multiple/Complex Needs
From the above list please
select the main support need
(number):
8. Type of Support Needed – please tick if relevant
None
Setting up / maintaining home & tenancy
None
Finance & budgeting
None
Dealing with correspondence
None
Maintaining the safety & security of the home
None
Living skills
None
Access to training & employment
None
Accessing the community
None
Managing relationships
None
Physical / mental health and wellbeing
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☐
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A little
A little
A little
A little
A little
A little
A little
A little
A little
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☐
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Some
Some
Some
Some
Some
Some
Some
Some
Some
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A lot
A lot
A lot
A lot
A lot
A lot
A lot
A lot
A lot
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Brief overview of
reasons for referral:
Please remember
that the main aims
of these services are
to support people to
maintain/manage
accommodation and
independence.
Note: this referral
will not be processed
unless this section is
complete.
9.
Risk Indicators (answering yes will not mean that the service user can’t have a service; it just enables us to make sure
the most suitable provision can be provided for their needs)
Yes
☐
No
☐
Don’t know
☐
Has applicant ever hurt anyone?
Yes
☐
No
☐
Don’t know
☐
Has applicant damaged any property/ belongings intentionally?
Yes
☐
No
☐
Don’t know
☐
Has applicant ever intentionally started a fire?
Yes
☐
No
☐
Don’t know
☐
Has applicant ever been in trouble with the police?
Yes
☐
No
☐
Don’t know
☐
Has applicant ever had a problem with illegal drugs alcohol?
Yes
☐
No
☐
Don’t know
☐
Has applicant ever tried to take their own life?
Yes
☐
No
☐
Don’t know
☐
Has the applicant ever intentionally harmed themselves?
Yes
☐
No
☐
Don’t know
☐
Is applicant involved in sexual violence?
Yes
☐
No
☐
Don’t know
☐
Is the applicant required to register with the Police under the Sex
Yes
☐
No
☐
Don’t know
☐
Yes
☐
No
☐
Don’t know
☐
Yes
☐
No
☐
Don’t know
☐
Is there a current Risk Assessment available? Please attach to this
application (failure to do so may delay the application
Offenders Act 1997/the Sex Offences Act 2003?
Has the applicant ever been violent towards a staff member of any
organisation?
Are there any risks concerning the applicants physical disability or
mobility?
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Are there any risks around any medication the applicant takes?
Yes
☐
No
☐
Don’t know
☐
Is the applicant at risk from other people?
Yes
☐
No
☐
Don’t know
☐
Do workers need to know anything about the service user before
Yes
☐
No
☐
Don’t know
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entering their home?
Please indicate if a joint visit is required for the initial contact assessment, or if an assessment in a safe place such as the
Information Station should be undertaken (This referral will NOT be processed unless this section is complete):
Lone Visit ☐
Other Information:
Joint Visit ☐
Information Station
☐
If you have answered yes to any of the above, please give more detail below (failure to do so may delay the application):
10. Current / Previous Support Received
(If known) please detail any previous/other current housing-related support received by applicant (floating or supported
housing) including any exclusions
11. Authorisation
Has the applicant consented to you sending this referral, along with the information contained, to the Council’s Supporting
People Team / Supported Housing Gateway?
Yes
☐
No
☐
Have you advised and sought agreement from the applicant that information contained within this document will be
forwarded to contracted support providers and may be shared with other agencies?
Yes
☐
No
☐
Where possible this form should be signed by the applicant. If the applicant has not signed this form the referrer must state
that verbal consent has been given for a referral to be made.
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Applicant’s Signature:
Date:
Or applicant’s verbal consent to referral:
Referrer’s Signature:
Yes
☐
No
☐
Date:
If not referring directly on to Abritas please email this form to:
for FLOATING SUPPORT: floating.support@newport.gov.uk
for SUPPORTED HOUSING: newport.gateway@newport.gov.uk
Please email to floating.support@newport.gov.uk if not sure which type of provision is appropriate
On receipt the applicant will be contacted in order to undertake a Support Needs Assessment
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--------------------------------------------------------------------------------------------------------------------------------------------------------To be completed by SPT:
1)
Risks checked on Social Services /Housing Database:
Yes

No

Yes

No

Yes

No

N/A

Details of known risks:
2)
Other SP services identified (previous or current)):
Details:
3)
Service exclusions identified:
Details:
4)
Referrer updated:
Yes

No

5)
Abritas / ‘Live’ spreadsheet updated:
Yes

No

6)
CRM / Case note added:
Yes

No

7)
Other Relevant Information:
8)
Referral e-mailed to Support Provider (if appropriate):
Yes

No

N/A

9)
Referral input to Abritas:
Yes

No

N/A

10) Application processed by:
__________________________________________________________
11) Date Processed:
__________________________________________________________
12) Date & Time of Assessment (if known):
__________________________________________________________
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